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HIM 200:Module 2 Journal
SNHU
Health records provide us with a complete and clear picture of an individual’s medical
background. This results in having the ability to deliver a higher quality of care. There
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are two forms of health records, paper and electronic. Paper health records usually are
based in one practice. This is because of the need of additional personnel to handle and
support the paper files and to organize countless documents. Paper health records are
still used in today’s health care systems. Electronic health records can be seen in bigger
practices, where fast and convenient patient data sharing is needed. An electronic health
record also requires fewer personnel, and no physical storage space. ”Paper health
records need to be faxed, scanned or mailed which is a time-consuming process; were as
electronic health records provide access to the patient data instantly. Time is critical in a
medical setting (Kivatinos, 2017).”
Health record information is organization by templets that fall under administrative or
clinical data. Socioeconomic information falls under administrative data which is used to
identify the patient. But you will find that consents for treatment, authorizations for use
and release of information are as well a part of administrative data. Clinical data refers
to collected and maintained data that relates to the patients’ health and course of
treatments and care; a patient’s medical history, laboratory results, drug prescriptions and
orders all fall under clinical data (McWay, 2014). Administrative and clinical data work
together to create the patient’s health record.
“If it's not documented in the medical record then it didn't happen”. This statement is
extremely important when it relates a patient’s diagnosis. How can any information
pertaining to a patient’s diagnosis be supported (the diagnosis confirmations, lab results,
test result, or physician notes) if it is not documented? All health records should contain
sufficient, accurate information to identify the patient, support the diagnosis, and justify
any the treatments (Walker & Nicholson, 2009). Health records, whether paper or
electronic gives us information to correctly identify a patient, and details of the patient’s
medical history (past and present). Health records are organized by templets or forms
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categorized by administrative or clinical data. Each form in the health record has its
effectiveness for use. The main objective is to remember health records, whether paper
or electronic, must be complete and accurate to provide supported and justified
information.
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References:
Kivatinos, D. (2017, May 02). Electronic Medical Records EHR vs. Paper Records.
Retrieved from https://blog.drchrono.com/paper-vs-electronic-medical-records
McWay, D. (2014). Today's Health Information Management (2nd ed., p. 123). New
York: DELMAR CENGAGE Learning.
Walker, S., & Nicholson, L. (2009). The relationship between Health Record
Documentation and Clinical Coding [Ebook] (p. 2). Retrieved from
https://ifhima.org/wpcontent/uploads/2014/08/the_relationship_between_hr_documentation_
and_codingfinalifhro.doc
